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Credit Card/Name - Payment Method

Optional email address(es) where we should send a payment receipt. (Separate multiple email addresses with a semicolon)

Address*

City*

State*

Postal Code*

* Indicates a required field

I authorize to collect $0.00 from my account.I hereby authorize to collect from my account the above amount. By checking the box I acknowledge that my account () will be stored and charged as outlined above. Payment is to be made when billed in accordance with the standard policy of the account holders bank. If I need to request a refund, I agree to contact as soon as possible to make the request, knowing that there may be circumstances that prevent such a refund from being made.